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Doctor: Any medical problems that run in the family? Patient: No, nothing that comes to mind.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Unremarkable.

Doctor: Hi Mister B, nurse tells me you had a fall? Patient: Yes, a pretty bad one. Doctor: Okay, tell me what happened? Patient: Well, I was running to catch a taxi and stumbled upon a piece of rock, lost my balance and fell. Patient: I fell face down and my head hit the sidewalk. The next thing I remember is I am all dazed and people trying to help me. Doctor: I see, did you lose consciousness after the fall? Patient: No. Doctor: So, is your head hurting? Patient: Only the right forehead where I have the scrape and my chin. Doctor: Okay, any neck or back pain? Patient: No. Doctor: Any stomach pain? Patient: No. Doctor: Pain anywhere else, in extremities, hand or leg? Patient: No. Doctor: Okay, and how old are you? Patient: I am forty two. Doctor: Okay.

Section Header: HISTORY of PRESENT ILLNESS Summary: Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk. He denies loss of consciousness but says he was dazed for a while after it happened. He complains of pain over the chin and right forehead where he has abrasions. He denies neck pain, back pain, extremity pain or pain in the abdomen.

Doctor: Let's talk about your family history. Patient: Okay. Doctor: Can you tell me about any kind of medical traits that run in your family? Patient: I think my family has been blessed or I don't know if any. Doctor: What about any heart disease? Patient: Nope. No heart disease or diabetes or any other kind of issues that I'm aware of.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Negative.

Doctor: Hello, Nurse. Could you give me a run down on the eleven month old patient? Guest_clinician: The patient was presented with stage two neuroblastoma on the left when he was six weeks old. It was completely resected. It was shown not to be N Myc amplified and had some favorable Shimada histology. Doctor: Great. Did he have a follow up after? Guest_clinician: He did. There was a second primary in his right adrenal gland. They performed a biopsy, which was consistent with neuroblastoma with favorable Shimada histology. Doctor: Did he receive any chemotherapy? Guest_clinician: He is now being treated with it per protocol P nine six four one and not on study. His last chemotherapy appointment was on May twenty first two thousand and seven. They used carboplatin, cyclophosphamide, and doxorubicin. Doctor: What did they do after chemotherapy? Guest_clinician: He received G C S F daily because he had neutropenia that delayed his second cycle. Doctor: Thank you, Nurse. I'll go talk to the mother. Guest_clinican: No problem, Doctor. Doctor: Hello, ma'am. It's nice to see you again. How is your little boy doing? Guest_family: Not so well. Since out last visit, he had a stuffy nose for a couple of days. Doctor: Is it getting worse? Guest_family: I think it's getting better now. It isn't as stuffy. Doctor: That's good to hear. Has he been sick or had any fevers? Guest_family: Nope. Just the stuffy nose. Doctor: Has he been able to eat anything? Guest_family: At times, he didn't want to eat. It seemed like he wasn't hungry. Doctor: Does he still have a reduced appetite? Guest_family: Not anymore. He's starting to eat again. Doctor: Did he have any nausea or vomiting after he ate? Guest_family: Thankfully, no. I would have made my husband clean up the vomit. Doctor: That's great. Is he able to pee and poop fine? No diarrhea, right? Guest_family: His poop has been solid. I haven't seen anything bad about his pee either. Doctor: Great. Would you be able to open his mouth for me? I just want to check if everything's fine inside. Guest_family: Of course. Say ah. Patient: Ah. Doctor: Thank you. Oh, wow. It looks like he's showing some symptoms of thrush again. Guest_family: Oh, no. Should we restart fluconazole? Doctor: It's just a fungal infection inside the mouth. I'll prescribe him fluconazole. It should get rid of it. Guest_family: Thank you so much. You all have been so helpful. My little boy is slowly getting better.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected. It was felt to be stage 2. It was not N-Myc amplified and had favorable Shimada histology. In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology. He is now being treated with chemotherapy per protocol P9641 and not on study. He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin. He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle. In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving. He is not acted ill or had any fevers. He has had somewhat diminished appetite, but it seems to be improving now. He is peeing and pooping normally and has not had any diarrhea. He did not have any appreciated nausea or vomiting. He has been restarted on fluconazole due to having redeveloped thrush recently.

Doctor: So, how are long have you had pain in this hip? Patient: It's been about eight or ten years now. It began while I was working in construction. Doctor: How old are you now? Patient: I'm thirty two now, so I've been in pain since I was in my twenties. Doctor: Have you seen another doctor for this, or am I the first? Patient: Yeah, um, I've actually seen several doctors before, the last I saw was Doctor A B C a few weeks ago. Doctor: What did those doctors tell you? Patient: They thought it was low back pain, and something called, um, radiculopathy. Doctor: Does your pain radiate into your legs? Patient: Yes. Doctor: Has your pain been present for the eight years, or did it come and go? Patient: It's been persistent, and I've had difficulties on and off since then. Doctor: Okay. The x rays from Doctor A B C show severe degenerative changes as well as avascular necrosis of the femoral head. What else did the Doctor do for you? Patient: He gave me some pain medicine, and we talked about going to another specialist for surgery. Doctor: Do you remember the names of the procedures suggested? Patient: Something about resurfacing the hip, or a hip replacement. I'm here for another opinion on that. Doctor: I saw you come in with a cane, do you have groin pain as well? Patient: Yes, and I can't do any of the activities I used to. Doctor: Besides the pain medication, have you had anything else? Patient: I've taken antibiotic steroids before. Doctor: Okay. Do you drink? Patient: Yes, a lot.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 32-year-old male seen by Dr. ABC several weeks ago for persistent left hip pain. He has a long eight to ten year history of pain into the left hip. He has been worked up by several specialists and evaluated. He was thought initially to have low back pain with radiculopathy. He does have a history of antibiotic steroid use as well as heavy drinking. He reports his symptoms started approximately eight years ago when he was doing some construction at which time he began to have left hip pain. He has had difficulties on and off ever since then. On the last visit, radiographs revealed severe degenerative changes of the left hip joint with apparent AVN of the left femoral head. He was given some pain medication and discussion took place regarding referring him to a specialist for evaluation of possible hip resurfacing versus conventional total hip replacement. He came for a second opinion in the area and we discussed his problems further. He continues to have primarily groin pain, which limits his daily activities. He has used a cane in the past for a short period and he continues to have difficulty with the left hip.

Doctor: Let me examine your skin. Patient: Sure. Doctor: It looks normal and well hydrated. Any excessive sweating? Patient: No, not really. Doctor: I don't see any injury or wounds. Patient: Yeah. Doctor: Its just a normal protocol to ask these questions for every new patient. Patient: I understand. Doctor: Thank you for your cooperation.

Section Header: EXAM Summary: SKIN: Inspection within normal limits. Well hydrated. No diaphoresis. No obvious wound.

Doctor: Hi there! I am Doctor Kirkland. Patient: Hi. Doctor: How are you feeling? Patient: I feel weird. Like I feel confused. I don't know how I got here. Doctor: That's okay. Do you remember what happened to you before you came here? Patient: No. Doctor: Can you tell me about your past medical history? Patient: Um. Doctor: Take your time. Patient: I can't think of what it is called. It's something to do with my brain. Doctor: Okay. Patient: My doctor knows what it is. Doctor: What is the name of your doctor? Patient: Doctor Frank. Doctor: Doctor X? Across the street? Patient: Yes, that is his name. I don't know if that is across the street or not. Doctor: I will have your nurse give him a call and get some background information from him. Patient: Okay. Doctor: Can you please give Doctor X a call and get mister Jones' medical history? Guest_clinician: Yes, of course. Doctor: Thank you.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient himself is not able to give a good history. History has obtained through discussion with Dr. X over the phone and the nurse taking care of the patient despite reviewing the chart on the floor.

Doctor: Any issues from head to toe? Patient: No, everything is fine.

Section Header: REVIEW OF SYSTEMS Summary: Noncontributory.

Doctor: Hello, it's been two months already? Patient: I know right? Doctor: Just feels like yesterday.

Section Header: CHIEF COMPLAINT Summary: The patient is here for two-month followup.

Doctor: Tell me about your family medical history. Patient: No one in my family has any health problems.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.

Doctor: And are you working? What do you do? Patient: Oh, I am a catholic priest! Doctor: Oh wow! Patient: Yes. Doctor: And if you don't mind me asking, do you drink alcohol? Patient: Maybe that is something for my confession box but jokes apart I don't drink. Doctor: Sorry I need to ask these questions it's a protocol. Patient: I understand. Doctor: And can I put down here that you don't smoke or use any kinds of drugs? Patient: Yes, I don't do those either. Doctor: Cool.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Catholic priest. Denied Tobacco/ETOH/illicit drug use.

Doctor: Okay, so where do you live? Patient: I live at an old age nursing home.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Not available. The patient lives at a skilled nursing facility.

Doctor: So, he is Arjun, and he is thirty seven years old and was complaining of chest pain. Patient: Hi Doctors, how are you? Doctor: We are good thanks for asking. Guest_clinician: Hi there Arjun, I am doctor J and I am assisting Doctor Wilson today. So, chest pain huh? Patient: Yep. Guest_clinician: And I see here no cardiac excretion was mentioned. Doctor: Yeah. I am suspecting coronary spasm but that's questionable. Guest_clinician: Okay. Doctor: I did run a cardiac enzyme profile and it was negative. Guest_clinician: Alright. And he also has hyperlipidemia? Doctor: Yes, he does. Guest_clinician: Okay and did you order an E K G? Doctor: I did, it is normal too. Guest_clinician: Don't worry Arjun, we will take of you. Patient: Thank you.

Section Header: ASSESSMENT Summary: 1. Chest pain in a 37-year-old gentleman with negative cardiac workup, questionably right coronary spasm. 2. Hyperlipidemia. 3. Negative EKG and cardiac enzyme profile.

Doctor: So, do you live in the area? Patient: Yes, my husband and I have lived here for a long time. He died a few years back. Doctor: I'm sorry to hear that. Patient: It's alright. Doctor: Do you smoke or drink? Patient: No, I don't. Doctor: Do you use any illicit drugs or substances? Patient: No, I don't do anything like that.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient lives locally. She is a widow. She does not smoke cigarettes or use illicit drugs.

Patient: Um, I take the generic for Ultracet. Sometimes I take as many as four times a day. Doctor: Does this help the pain? Patient: No, I'm still in pretty significant pain, doctor. Doctor: Good morning, sir. My nurse's chart says that you're thirty four years old. Is that correct? Patient: Yes, doctor, that's correct. Doctor: How long have you had this back pain? Patient: Well, it's been a while now. Doctor: Does the pain go into your legs? Patient: Yes, into the left leg, more towards the outside of my leg. Doctor: Is there any injury that started this pain? Patient: Yeah, I was lifting at work on August twenty seventh two thousand three when I lifted something and felt a pretty sharp pain from my back down into my left leg. Doctor: Have you had back pain or surgeries before this injury? Patient: No, I haven't. Doctor: Are you having weakness in the legs? Patient: Yes, I am. Doctor: Okay, I believe you are a good candidate for surgery, sir. It seems like you have a lot of weakness and pain in the S one nerve root distribution. Patient: Okay. What are the risks of infection for this surgery? Doctor: Overall, the risk of infection is very low, less than one percent. We use antibiotics to control for infection the entire time. Patient: Will I be asleep for the surgery? Doctor: Yes, you'll be under anesthesia. You won't feel a thing. Patient: Okay, yes. I'd like to do the surgery.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution. The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity. He denied any previous history of back pain or back surgeries. Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on. After an informed consent was obtained, all risks as well as complications were discussed with the patient.

Doctor: Hello, miss. Doctor X and I will be going over your medical history with you. Before we begin, could you confirm your age for me? Patient: I'm twenty five years old. Doctor: Thank you. Doctor X, could you go over the diagnosis of erythema nodosum? Doctor_2: She was diagnosed in two thousand and four after a biopsy was done that confirmed erythema nodosum, but the detail from the Netherlands is not that specific. Doctor: What kind of procedures were done to address it? Doctor_2: She had undergone a colonoscopy to address secondary diseases that may have been present because of the erythema nodosum, correct miss? Patient: Yeah, that's correct. Doctor: Were there any findings, Doctor X? Doctor_2: The findings were uncertain if the terminal ileum had abnormal biopsies. However, the skin biopsy mentioned some fibrosis, basal proliferation, and inflammatory cells in the subcutis. Doctor: I see. Her report states something about a tibia and fibula fracture on her right leg before the erythema nodosum. Are these skin lesions due to the fracture? Doctor_2: The skin lesions are not associated with the fracture, correct ma'am? Patient: That's correct. The cuts in my skins are on both legs too. Not just the right. Doctor: Thank you. Did anything occur before the skin lesions? Doctor_2: She had cosmetic surgery done on her jaw. Doctor: Ma'am, I see you visited our clinic and the Dermatology several times, correct? Patient: Yeah, that's correct. I had a rash that I wanted to get checked. Doctor_2: I remember that. I was here when she presented the rash. We suggested the rash in her lower extremities and ankles was erythema nodosum. She also had discomfort, which could have been inflammatory arthritis. Doctor: Doctor X, did you confirm with any tests? Doctor_2: Yes. There was an initial S E D above one hundred and ten and her C P R was increased. Doctor: Great. In the visits after, were there any other problems found? Doctor_2: The reports says that no other abnormalities were found. However, I do see something about her first visit. Doctor: Could you explain what it says? Doctor_2: She has some M T P detected, which could have been signs of erythema nodosum. However, the Dermatology did not agree, and they believed it to be venous stasis. Doctor: The venous stasis could have been related to the fracture, right? Doctor_2: That is correct. Doctor: Her initial visit reports suspicion of I B D, sarcoid inflammatory arthropathy, and lupus. Why was that? Doctor_2: She had a questionable rheumatoid fracture even though her C C P was negative. Her A N A was positive at one to four zero. There was a persistent speckled pattern. However, the rest of the lupus serologies were negative. Doctor: What lupus serologies were used? Doctor_2: Double stranded D N A, R N P, Smith, R O, and L A were used. Doctor: How did her cardiolipin antibodies panel look? Doctor_2: They were all negative. We made sure I g M, I g G, and I g A were less than ten. Doctor: I see. Was there anything else in the report? Doctor_2: She had her beta 2 glycoprotein one or R V V T tested. Doctor: That seems important because of the livedo pattern. Doctor_2: Exactly. That's why they concluded it was an onset of lupus and not rheumatoid arthritis because the arthritis couldn't be associated with erythema nodosum. Doctor: Why did she undergo a C T scan? Doctor_2: We feared she had lymphoma. The scan of her chest, abdomen, and pelvis were done to rule out sarcoid. Doctor: I see. The results came out normal, right? Doctor_2: That's correct. Doctor: Did you change some of you habits to help your bowels, ma'am? Patient: I tried my best to. Doctor: That's good. What was found Doctor X? Doctor_2: There was evidence of B twelve deficiency with a high methylmalonic and high homocystine levels along with a low normal B twelve in addition to iron studies consistent with iron deficiency and an initially low M C V. Doctor: That gives the possibility of inflammatory bowel disease, right? Doctor_2: Correct. That's stated in the report. Doctor: Were there any tests done to confirm this? Doctor_2: She underwent a colonoscopy, which showed nothing. Her endoscopy was also normal. Recently, she underwent a second coloscopy, and no evidence of inflammatory bowel disease was seen after viewing it microscopically. Doctor: Nothing was seen microscopically? Doctor_2: Actually, we determined there were aggregates of eosinophils. Doctor: That sounds important. That could be due to an allergic reaction or an emergence of Crohn Disease. I will have to discuss with Doctor Y from Gastroenterology to see the significance. Patient: Could I interrupt for a second? I don't think my B twelve and iron deficiency were looked at while I stayed in the United States. Doctor: Is that correct, Doctor X? Doctor_2: That is. I think these details were from somewhere else. Doctor: At least we are aware of it. What medication was provided during her first visit? Doctor_2: It looks like she was placed on forty milligrams of prednisone. The strength was reduced over time. Doctor: This may be a reason to her acne. Was she taken off this medication? Doctor_2: Yes, she was. There were too many adverse effects. Doctor: What was she places on after? Doctor_2: It looks like she started a point six m g colchicine, which she took daily. Doctor: How were her inflammatory markers after taking it? Doctor_2: Her markers were under control and positive. She also didn't have any evidence of erythema nodosum. Doctor: That is great. How did you like that medication, ma'am? Patient: My ankle would swell up and hurt. There were also some sensitive rashes on the skin of my legs. Doctor: I see. Is that stated on the report, Doctor X? Doctor_2: It is. I also see that she was reevaluated by Dermatology. Doctor: Did they find anything apparent? Doctor_2: No, they didn't. They didn't find any evidence of erythema nodosum. Doctor: What was the plan following that? Docotr_2: It looks like we proceeded with a D E X A scan and checked her vitamin D levels. Doctor: Was there any medication prescribed? Doctor_2: We ordered vitamin D and calcium to be bought over the counter so that her bones were protected. However, they use of them was stopped until we figured out the underlying cause of her disease. Doctor: I see. Other than the fracture and jaw surgery, was there anything else? Doctor_2: It shows she had Varicella and Mononucleosis, correct ma'am? Patient: Yeah, that's correct. Doctor: That's good. Our recent physical exam with you from last August showed changes in your venous stasis and diffuse periarticular ankle edema. Fortunately, we did not find any erythema nodosum, but the livedo patter was still present. Patient: I see. Did you find anything else? Doctor: We did find a heart murmur, so we will conduct an echocardiogram. Doctor X, could you confirm all the details form the workup, please? Doctor_2: Of course. Her A C E levels were normal. Her sed rate was around 30, which was high. Before that, it was around one ten, which is even higher. Her R V V T was normal. The rheumatoid factor was negative. The urinalysis was also normal. She had a C R P level of two point three, which was high. Her C C P came out negative. Her C B C displayed microcytosis and hypochromia with hematocrit levels of thirty seven point seven. Her hematocrit levels improved to forty point three later on, and she did not have any hypochromia, microcytosis, or anemia present. Doctor: Thank you for all that information. Does all this information and history seem to be correct, ma'am? Patient: Yes. Thank you for going over that in front of me. Doctor: No problem. I see you're here today regarding some mild but intense skin rashes. You mentioned that you thought it was erythema nodosum, correct? Patient: Yeah, that's correct. I think it's on my ankles. I also feel some joint stiffness. Doctor: I will take note of that. You also mentioned something about a rash before. Did you have a rash that was sensitive to U V light, like sunlight? Patient: That's right. I had it twice when I was in Europe. Doctor: When did you notice the rashes? Patient: I was skiing, and my face started to swell up. Doctor: I see. Do you think it had to do anything with your acne? Patient: No. My acne was stable after I stopped taking that one medicine and started the other. Doctor: The prednisone and colchicine we mentioned earlier, correct? Patient: That's correct. Doctor: Is there anything else you would like to ask? Patient: I am trying to get pregnant and would like to know if the medication has any effects on pregnancy. Doctor: I'll discus that with you right now. Patient: Actually, could you provide me with a pamphlet? I need to go study for my psychology classes. I have a big test tomorrow.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 25-year-old woman who is attending psychology classes. She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in Netherlands. At that point, she had undergone workup which was extensive for secondary diseases associated with erythema nodosum. Part of her workup included a colonoscopy. The findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum. The skin biopsy, in particular, mentions some fibrosis, basal proliferation, and inflammatory cells in the subcutis. Prior to the onset of her erythema nodosum, she had a tibia-fibula fracture several years before on the right, which was not temporarily associated with the skin lesions, which are present in both legs anyway. Even, a jaw cosmetic surgery she underwent was long before she started developing her skin lesions. She was seen in our clinic and by Dermatology on several occasions. Apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased CRP. In the following visits, no evident abnormality has been detected. In the first visit, here some MTP discomfort detected. It was thought that erythema nodosum may be present. However, the evaluation of Dermatology did not concur and it was thought that the patient had venous stasis, which could be related to her prior fracture. When she was initially seen here, a suspicion of IBD, sarcoid inflammatory arthropathy, and lupus was raised. She had an equivocal rheumatoid fracture, but her CCP was negative. She had an ANA, which was positive at 1:40 with a speckled pattern persistently, but the rest of the lupus serologies including double-stranded DNA, RNP, Smith, Ro, La were negative. Her cardiolipin panel antibodies were negative as well. We followed the IgM, IgG, and IgA being less than 10. However, she did have a beta-2 glycoprotein 1 or an RVVT tested and this may be important since she has a livedo pattern. It was thought that the onset of lupus may be the case. It was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum. For the fear of possible lymphoma, she underwent CT of the chest, abdomen, and pelvis. It was done also in order to rule out sarcoid and the result was unremarkable. Based on some changes in her bowel habits and evidence of B12 deficiency with a high methylmalonic and high homocystine levels along with a low normal B12 in addition to iron studies consistent with iron deficiency and an initially low MCV, the possibility of inflammatory bowel disease was employed. The patient underwent an initially unrevealing colonoscopy and a capsule endoscopy, which was normal. A second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen. However, eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging Crohn disease and I will need to discuss with Gastroenterology what is the significance of that. Her possible B12 deficiency and iron deficiency were never addressed during her stay here in the United States. In the initial appointment, she was placed on prednisone 40 mg, which was gradually titrated down this led to an exacerbation of her acne. We decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily. While this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum, the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain. She was reevaluated by Dermatology for that and no evidence of erythema nodosum was felt to be present. Out plan was to proceed with a DEXA scan, at some point check a vitamin D level, and order vitamin D and calcium over the counter for bone protection purposes. However, the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease. Her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis. Her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until I took over her care last August. I have not been able to detect any erythema nodosum, however, a livedo pattern has been detected consistently. She also has evidence of acne, which does not seem to be present at the moment. She also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed. Her workup during the initial appointment included an ACE level, which was normal. She also had a rather higher sed rate up to 30, but prior to that, per report, it was even higher, above 110. Her RVVT was normal, her rheumatoid factor was negative. Her ANA was 1:40, speckled pattern. The double-stranded DNA was negative. Her RNP and Smith were negative as well. RO and LA were negative and cardiolipin antibodies were negative as well. A urinalysis at the moment was completely normal. A CRP was 2.3 in the initial appointment, which was high. A CCP was negative. Her CBC had shown microcytosis and hypochromia with a hematocrit of 37.7. This improved later without any evidence of hypochromia, microcytosis or anemia with a hematocrit of 40.3. The patient returns here today, as I mentioned, complaining of milder bouts of skin rash, which she calls erythema nodosum, which is accompanied by arthralgias, especially in the ankles. I am mentioning here that photosensitivity rash was mentioned in the past. She tells me that she had it twice back in Europe after skiing where her whole face was swollen. Her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily. Today we discussed about the effect of colchicine on a possible pregnancy.

Doctor: Anyone sick in your family? Patient: Nope. Doctor: So, everyone is healthy? Patient: That's right.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Unremarkable.

Doctor: Mister Sunil, your blood pressure is high, and I am noticing this from past two-three times you have been here. It's been constantly high, you are not taking it seriously. Patient: No, nothing like that Doctor! It's been well under control. I have been monitoring at home. Doctor: Are you noting your readings? Did you bring it with you? Patient: No. I did not get the readings with me but I assure you I am taking care and my B P is normal. Doctor: Well, it's up and I am little bothered by it.

Section Header: HISTORY of PRESENT ILLNESS Summary: His blood pressure up. The last two to three times he has been in here, it has been up. He has assured me before that his blood pressure is under good control at home, but he does not bring any blood pressures in with him this time, which bothers me.

Doctor: What is your family medical history? Patient: My dad had colon cancer. Doctor: Did your dad pass from colon cancer? Patient: No. They caught it early. He passed away from old age. My mom passed away when she was in her nineties from a stroke. Doctor: I am sorry. Do you have any family history of any neurological disorders like, M S, Alzheimer's, Parkinson's or epilepsy? Patient: Other then my mom having a stroke, I know of nothing else.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: His mother died of a stroke in her 90s. His father had colon cancer. He is unaware of any family members with neurological disorders.

Doctor: Hello. I see you're here for a follow up. Did you get your blood work done? Patient: I did. Here are the results. Doctor: Let me take a look. Oh, wow. It looks like your blood sugar is high. Are you exercising every day? Patient: Not really. Is that bad? Doctor: You are at risk of developing type two diabetes.

Section Header: PAST MEDICAL HISTORY Summary: Adult-onset diabetes.

Doctor: Have you had ever had surgery? Patient: Yeah, I had my gallbladder removed a few years ago. Doctor: Thank you, what about any other parts of the body, like your eyes, ears, or nose? Patient: Oh yeah, I forgot. I had eye surgery too. Doctor: Thank you, think hard, any other surgeries you can remember? Patient: Let me look at my notes, um, it looks like I had a dilation and curettage done some time back, too. Doctor: I see. Thank you for sharing that with me.

Section Header: PAST SURGICAL HISTORY Summary: Cholecystectomy, eye surgery, D&C.

Doctor: Hi there! How are you doing? Patient: Um. I am feeing really strange. Doctor: Strange how? Patient: I took Ecstasy over the weekend and I feel weird still. My heart is racing. I feel agitated and have been having waves of sadness. I cannot shake this feeling. Doctor: When did you take the Ecstasy? Patient: On Saturday.

Section Header: CHIEF COMPLAINT Summary: "I took Ecstasy."

Doctor: Do you live alone? Patient: I do. I lost my husband to prostate cancer last year. Doctor: Oh wow. I'm so deeply sorry for your loss. Losing a loved one is incredibly difficult. I lost my sister to cervical cancer two years ago. It was one of the hardest experiences of my life. Patient: I'm sorry for your loss as well. It helps to remember the positive memories you had with them. Doctor: Yes, definitely. How have you been doing otherwise? Patient: Not bad. I've been keeping myself busy with gardening. Doctor: Gardening is a great hobby. Patient: Yes, I enjoy it very much. It brings me a lot of peace. Doctor: And as your doctor I have to ask, but any history of alcohol or drug use? Patient: No.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is a widow, lives alone. Denies any tobacco or alcohol use.

Doctor: Hello. How are you doing today? Patient: I feel depressed. Doctor: I'm sorry to hear that. What's been happening? Patient: My parents were fighting for a long time, and I think they're not together anymore. Doctor: That must be really hard. I'm sorry to hear that they're divorced. Who do you live with right now? Patient: I usually hop houses. I'll go to my dad's house the first half of the week and spend time with his family. Then, I'll go to my mom's house during the last half of the week. Doctor: That's nice. Now you can ask for more gifts during Christmas. Patient: You know what? I never thought about that. That's a really good idea.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient's parents continued to undergo a separation and divorce. The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.

Doctor: What do you do for a living? Patient: I'm a real estate agent. Doctor: How long have you been working in the real estate business? Patient: Almost twenty years. Doctor: Wow. I know who to go to when I'm looking to buy a house. Patient: Happy to help. Doctor: So let's see here. Do you drink or smoke? Patient: I drink socially, but it's very infrequent. Doctor: And I have to ask, but any drug use? Patient: Nope. Not now, not ever.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: No tobacco use, occasional EtOH, no known drug use, works as a real estate agent.

Doctor: Welcome back in, Miss A. Patient: Thank you, doctor. Doctor: Do you remember the information about your operation? Patient: No, not really. Can you remind me? Doctor: Sure, you had a lap band replacement in January of O nine, and you had a band adjustment. Patient: Thank you. Doctor: How are you feeling today? Patient: Well, I've been under a lot of stress lately, and I had problems with my adjustments before. Doctor: Has anything changed since the operation? Patient: Actually, doctor, I was in a car accident a couple weeks ago, and I'm having problems. Doctor: What symptoms are you experiencing? Patient: I don't feel full. Doctor: How is your appetite? Patient: I'm not really hungry, but I also don't feel full. When I get hungry at night I can't wait until the morning to eat. I get so hungry. Doctor: Do you eat anything when you feel like this? Patient: Yeah, I usually have a candy bar, and that helps some.

Section Header: HISTORY of PRESENT ILLNESS Summary: Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment. Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress. She was in a car accident a couple of weeks ago and she has problems, she does not feel full. She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.

Doctor: So, where do you live? Patient: Ah, I now live in an assisted nursing facility. Doctor: Okay, and do you drink or smoke? Patient: No, neither.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is a nondrinker and nonsmoker and currently lives at the skilled nursing facility.

Doctor: Any specific medical traits in the family? Patient: What do you mean by that? Doctor: I meant does anyone in your family or extended family have any medical problems that they were treated for? Patient: I'm not aware of any such thing in my family.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Unremarkable.

Doctor: Welcome in! I am Doctor Madison. Patient: Thank you. It's nice to meet you. Doctor: Are you married? Patient: Yes. We just got hitched last year. Doctor: Congratulations! Patient: Thank you. Doctor: Do you drink alcohol? Patient: No, I don't drink. Doctor: Do you smoke cigarettes? Patient: Yes. I know it's bad for me. Doctor: How much do you smoke per day? Patient: About a pack a day. Doctor: Okay. I have a lot of tools to help you quit smoking that we can discuss. Patient: Okay.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Marital status: Married. The patient smokes 1 pack of cigarettes per day. Denies use of alcohol.

Doctor: We have you scheduled for a follow up and to have the staples removed in one week with Doctor X Y Z. Do you have your wound care instructions? Patient: Yes. Doctor: Do you have any questions? Patient: No. Doctor: If you do have questions or concerns that may come up, please don't hesitate to call the office. Patient: Okay. Doctor: If you develop a fever greater than one hundred and one point four, chills, nausea, vomiting, or continuing diarrhea please call the office. Also if your incision site becomes red, warm to the touch or has any drainage, call the office. Patient: Okay.

Section Header: PLAN Summary: The patient was instructed to contact us with any questions or concerns that may arise. In addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site. He will be seen in about one week's time in Dr. XYZ's clinic and his staples will be removed at that time.

Doctor: Have you had sinus issues before? Patient: I am not sure, maybe on and off. Doctor: Because this is more allergic. Patient: Okay. Doctor: So, we call it allergic rhinitis. Patient: Is it different than sinus infection? Doctor: Yes, it's it is different. Patient: Okay.

Section Header: ASSESSMENT Summary: I think this is still his allergic rhinitis rather than a sinus infection.

Doctor: She has a rare case of thrombocytopenia. I'd like her to come in for a consult. Guest_clinician: Any other medical history? Doctor: No, just the thrombocytopenia.

Section Header: CHIEF COMPLAINT Summary: Thrombocytopenia.

Doctor: Hi there how are you? Patient: I am good no problem at all other than the usual. Doctor: And what is that? Patient: You know, some discomfort I have on my right side. I have been feeling that since I had a stroke five years back. Doctor: Right, right. We did an E M G right? Patient: Yes. Doctor: And none of the medications we tried are helping? Patient: No, I also saw a neurologist, but nothing is helping Doctor: Okay, and are you monitoring your sugar regularly? Patient: Oh yes, Everyday at least two to three times a day. Doctor: And how bout insulin dose? Patient: Oh, that I kind of adjust myself. Doctor: Well, I have rechecked all the symptoms and everything looks fine. I don't see anything out of order, but we will keep monitoring. Patient: Okay. Doctor: And you are not smoking or drinking again are you? Patient: No, not since I had the stroke. Doctor: In the past you had a history of heavy usage of both alcohol and smoking, you need to be careful. You are seventy years old. Patient: Yeah, I am taking care of it. Doctor: Alright take care then.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medications and it just does not seem to help. He checks his blood sugars at home two to three times a day. He kind of adjusts his own insulin himself. Re-evaluation of symptoms is essentially negative. He has a past history of heavy tobacco and alcohol usage.

Doctor: What is the strength of your Omeprazole? Patient: It is forty M G and I take it just once a day. Doctor: Any herbal medication? Patient: No I do not take anything like that.

Section Header: MEDICATIONS Summary: Omeprazole 40 mg once a day. Denies herbal medications.

Doctor: So, to double check, you have a history of hay fever and asthma, correct? Patient: Yes. I was also recently diagnosed with cervical dysplasia. I found out shortly after my last O B G Y N visit. Doctor: And are you planning to follow up with your O B G Y N in the upcoming months? Patient: Yeah, the next visit is scheduled and everything.

Section Header: PAST MEDICAL HISTORY Summary: Significant for asthma, allergic rhinitis and cervical dysplasia.

Doctor: So, do you have any family history of arthritis? Patient: Fortunately, no, not that I know of. Doctor: So, as far as you know, no one has had a joint replacement? Patient: No, it doesn't ring any bells.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.

Doctor: Please, tell me about your medical history. Patient: I've been dealing with depression and anxiety for some time now. Doctor: I'm sorry, that must be difficult. Patient: Thank you, it is, but I manage. Doctor: What about your joints? How do you move? Patient: Oh yes, I have arthritis as well. I also had sciatic pain a long time ago, and a herniated disk. Doctor: Have you ever had neurological symptoms, like headaches, blurry vision, or weakness? Patient: Actually yes, I have migraines when I'm having my period. Doctor: Thank you, and have you had any surgery in the past? Patient: Yes, I had my appendix out.

Section Header: PAST MEDICAL HISTORY Summary: Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy.

Doctor: Do you have any past history of psychiatric treatment of struggles? Patient: I had some extreme fatigue back in nineteen ninety one. I was in therapy for six years. They had me on Prozac. I took in for that whole six years while I was in therapy. When I started the Prozac, I had just started working again. The stress at work was overwhelming. Doctor: Was this the first time that you had feelings for fatigue and depression? Patient: No. I have always had a little sadness or depressed time in my life but it had been manageable before all the work stress started happening. Doctor: How are you feeling these days? Patient: I get somewhat sad from time to time but I don't dwell on things anymore. Doctor: Do you ever have thoughts of selfharm or suicidal thoughts? Patient: No.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue. She was also taking Prozac during that time. She then began taking Prozac again when she started working at secondary to stress with the work situation. She reported a chronic history of mild sadness or depression, which was relatively stable. When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things. She denied any history of suicidal ideation or homicidal ideation.

Doctor: How many other children do you have? Guest_family: My husband and I have three children, your patient today, and another boy, and girl. Doctor: How is everyone else doing? Guest_family: They're all doing very well, thank you for asking. Doctor: Do you live here in Easton? Guest_family: Yes, born and raised. Doctor: Good, do you have any pets? Guest_family: We have four dogs, three cats, and three mules. Doctor: What, no deer? Guest_family: No, no deer, at least not anymore. Doctor: What grade are you in, young man? Patient: I'm in the second grade, doctor. Doctor: Good, how do you like P E? Are you able to play no problem? Patient: Yes, I love P E. I don't have any problems there.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He lives with mom, dad, brother, sister, and everybody is healthy. They live in Easton. They have 4 dogs, 3 cats, 3 mules and no deer. At school, he is in second grade and he is doing PE without any limitation.

Doctor: So let's start from the beginning. Patient: Okay. Doctor: You're seventy nine years old, correct? Patient: Yes. Doctor: Right or left handed? Patient: Right. Doctor: Do you remember when you had your first fall? Patient: Hm about a year and a half ago I fell while trying to walk from my bed to the living room. Doctor: Did you feel lightheaded prior? Patient: Uh yeah I did have some lightheadedness and I was a bit confused. I was aware of my surroundings though. My legs just gave out and the next thing I knew I was on the floor. Doctor: I see. Did you lose consciousness? Patient: No, thank goodness. Guest_family: He got up by himself and felt fine afterwards. The strangest thing. Patient: Yeah. I was good until my legs gave out on me July third of O eight. Doctor: Did you experience the same lightheadedness as before? Patient: Not this time. Guest_family: We had to rush him to the hospital after that. Patient: I was later diagnosed with pneumonia. The fall was blamed on the pneumonia. Doctor: Got it. Patient: To be on the safe side, I started using a walker from then on. Doctor: Did you need any type of walking assistance prior to your falls? Patient: Nope. I used to walk about two miles a day before all of this stuff started happening to me. This isn't even the end of it. My legs gave out on me again August O eight. No lightheadedness beforehand, but they did find that I had pneumonia again. Guest_family: They admitted him to the hospital and later sent him for rehab. Doctor: Did rehab help? Patient: Yeah. I was able to use my walker after that. Doctor: Did you return to your previous health? Patient: Uh not really, no. I had another fall in October O eight. Doctor: Did they diagnose you with pneumonia again? Patient: Yeah. I also had shingles. Doctor: Are you currently living at home? Patient: I'm living in a Chronic Rehab Unit. I can't use my walker anymore. I'm confined to a wheelchair. Doctor: I'm sorry to hear that. Patient: On top of that, I've noticed that my hands have been numb for the past three weeks. Doctor: Is it all of your fingers or only some? Patient: All. Doctor: Are you noticing any other symptoms along with the numbness in your fingers? Patient: Yes. I feel like I've lost quite a bit of muscle in my hands. They're also much weaker than before. My strength hasn't been the same since July O eight. It's definitely getting worse. Doctor: I see. Patient: I've had muscle twitching in my legs since August O eight. Doctor: Fasciculations? Patient: Yes. In my lower legs and thighs. Doctor: Any cramping or problems swallowing? Patient: No. Doctor: Any difficulty breathing? Patient: No. Doctor: Any constipation or diarrhea? Patient: Both actually. It tends to alternate. Doctor: But no loss of bowel or bladder control? Patient: No. I've noticed that my blood pressure has been out of whack. I also feel like I'm about to faint anytime I stand. Doctor: Okay. Patient: I don't think I have much feeling in my feet. They feel like sponges. Doctor: How long has that been going on? Patient: Uh nine months or so. I lost joint position sense in my feet around that time, too.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom. At that time, he reports both legs gave away on him and he fell. He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him. He was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal. He was then well until the 3rd of July 2008 when his legs again gave way on him. This was not preceded by lightheadedness. He was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia. He started using a walker from that time, prior to that he was able to walk approximately two miles per day. He again had a fall in August of 2008 after his legs gave way. Again, there was no lightheadedness associated with this. He was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this. He did not, however, return to the pre-July baseline. In October of 2008, after another fall, he was found to have pneumonia again and shingles. He is currently in a Chronic Rehabilitation Unit. He cannot use a walker and uses a wheelchair for everything. He states that his hands have been numb, involving all the fingers of both hands for the past three weeks. He is also losing muscle bulk in his hands and has noticed some general weakness of his hands. He does, however, note that strength in his hands has not been normal since July 2008, but it is clearly getting worse. He has been aware of some fasciculations in his legs starting in August 2008, these are present both in the lower legs and the thighs. He does not report any cramps, problems with swallowing or problems with breathing. He reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder. He has had some problems with blood pressure drops, and does feel presyncopal when he stands. He also reports that he has no feeling in his feet, and that his feet feel like sponges. This has been present for about nine months. He has also lost joint position sense in his feet for approximately nine months.

Doctor: Are you still doing water aerobics? Patient: Yeah, I've been hitting the pool five days outta the week. Doctor: How're you feeling? Have you noticed any changes in energy and strength? Patient: I feel a bit stronger now compared to when I first started. I'm also way, way more energized.

Section Header: PLAN Summary: As tolerated. Continue water exercise five days a week.

Doctor: Do you have any history of chronic pain? Patient: I got into a car accident a long time ago and I have always had neck pain. Doctor: Okay. Any other pain throughout the body? Patient: Sometimes I have back pain. Doctor: Okay.

Section Header: HISTORY of PRESENT ILLNESS Summary: Back and neck pain.

Doctor: How is your pain today? Patient: Eh it's been a rough few days that's for sure. The pain started almost instantly. Doctor: I'm sorry to hear that. Have you been taking anything for it? Patient: I actually saw a chiropractor the other day. My neck pain has been unbearable. Doctor: Is the pain localized to one area? Patient: Yeah. Doctor: And it hasn't radiated to any other part of your body? Patient: Nope. Doctor: Are you experiencing a pins and needles sensation at all? Patient: Not yet. Doctor: Any back pain? Patient: Oh yeah. I'd say it's even worse than my neck pain. The pain starts in my lower back and radiates down both legs. Doctor: Any pins and needles as a result of this back pain? Patient: No, no pins and needles. Doctor: Are you experiencing stiffness in your back? Patient: The stiffness seems to worsen when I exert myself during activities. Doctor: Has it impacted your sleep at all? Patient: Honestly, I haven't gotten much sleep since the accident. It's been so difficult to find a comfortable position to sleep in. I've never had back problems until now. Doctor: This accident sure did a number on you. Patient: No kidding. Doctor: You had mentioned experiencing stiffness during strenuous activity. Is it mostly during the day or does it progress into the night? Patient: Yeah, it's mostly during the day. Doctor: I see. Patient: The pain does improve a bit when I lay flat or sit up in a chair. Doctor: But despite this, your activity continues to be restricted, correct? Patient: Yeah, correct. Doctor: I meant to ask if you felt better after chiropractic treatment? Patient: A little bit, but not much. Doctor: And would you say your pain has overall gotten worse or remained the same? Patient: It's stayed more or less the same. Doctor: And to confirm, you didn't have neck or lower back problems prior to the accident? Patient: Yeah.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains localized and is non-radiating. There are no associated paresthesias. Back pain originates in the lumbar region and radiates down both lower extremities. Back pain is characterized as worse than the neck pain. There are no associated paresthesias. Stiffness is provoked by attempts at strenuous activity. The patient also reports difficulty sleeping, unable to find a comfortable position. The patient denies any previous back problems. During the day, the pain is exacerbated by strenuous activities. Pain may be eased by resting or recumbency and sitting. The patient's activity level has been significantly restricted. Some improvement has been noted with chiropractic treatment. Since the onset of the problem, the pain has continued at more less the same level. The patient reports that, prior to the present problem described above, there had been no episodes of neck or lower back pain.

Doctor: I have reviewed your x rays from your emergency room visit. I agree with Doctor Jones that your lungs show no signs of infection or decreased lung capacity. Patient: Okay.

Section Header: IMAGING Summary: Chest x-ray ordered by ER physician is unremarkable, but to me also.

Doctor: Hello, how are you doing? What brings you here? Patient: I think I have allergies. I used to live in Seattle. I had allergies there, but I think they're getting worse after moving here. You see, I'm twenty three and I am a white female. I was in Seattle, I thought that the weather there is not for me. That's why I plan to move on here, but my allergies are not leaving me here either. Doctor: What did you take for your allergies before? Patient: Claritin and Zyrtec. Doctor: How effective were they? Patient: They seemed to be working for some time, but now I feel like nothing is effective anymore. Doctor: Have you ever tried Allegra? Patient: Yes, I tried that last summer and I've started it again like two weeks ago. But again, the story is the same. They work for some time and now it doesn't seem to be working anymore. Doctor: Have you tried sprays? Patient: I did use some over the counter ones. But I never got any prescribed nasal spray. Doctor: Any other medically related history that I should be aware of? Patient: I do have asthma if that counts. Doctor: Are you taking any medications for your asthma? Patient: Nope, nothing on the regular basis. Doctor: Do you think it is your asthma that is flaring up? Patient: I don't think so. I think, I still think it is just some allergies. I want to get tested.

Section Header: HISTORY of PRESENT ILLNESS Summary: This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effectiveness. She has used Allegra also. She used that last summer and she began using it again two weeks ago. It does not appear to be working very well. She has used over-the-counter sprays but no prescription nasal sprays. She does have asthma but doest not require daily medication for this and does not think it is flaring up.

Doctor: Good afternoon, ma'am. Patient: Good afternoon doctor. Doctor: So, do you have any medical conditions I should know about. Patient: Actually, yes. I have a few. I have hyperthyroidism, and I've had gallbladder issues for some time now. Doctor: I see. How's your blood pressure? Patient: Oh, um, I have high blood pressure too.

Section Header: PAST MEDICAL HISTORY Summary: The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.

Doctor: Are you a smoker, sir? Patient: Yes, I've been smoking about a pack, to about a pack and a half a day for more than forty years now. Doctor: What about alcohol, do you drink? Patient: Yeah, I drink a six pack of beer a day, doctor. Doctor: What about drugs? Do you use any illicit substances? Patient: No, I never used anything like that.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient smoked 1-1/2 packs for more than 40 years. He consumes 6 beers per day. He denies any drug use.

Doctor: I'd like her to come see you for a consult tomorrow. Guest_clinician: How long has she been suffering from migraines with aura? Doctor: About five years now. Guest_clinician: Does she have a neurologist she sees regularly? Doctor: Not since moving here.

Section Header: DIAGNOSIS Summary: Migraine with aura.

Doctor: So, sir, are you married? Patient: Yes, I'm married to my lovely wife. Doctor: That's great, so, what did you do for a living? Patient: I was a Pepsi Cola truck driver, but thankfully, I'm retired. Doctor: Congratulations on your retirement. What seems to be the problem today then? Patient: Thank you, it's nice to be done with that. The years took their toll though, I have a lot of pain in my back and knees. Doctor: Ah, yes, those years of sitting and lifting eventually catch up to everyone.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Married. He is retired, being a Pepsi-Cola driver secondary to his back and knees.

Doctor: Tell me about your family medical history. Patient: The only thing that I know about is that my grandma has diabetes.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Positive for diabetes mellitus in the maternal grandmother.

Doctor: Hello, Mister G, how are you today? Patient: I am good doctor thank you for asking. I am here to talk to you about my will. Doctor: Yeah, nurse informed me. So, tell me how can I help you? Patient: As you know I have terminal cancer. I have decided I do not want to be resuscitated. I have appointed my daughter as my legal healthcare proxy and she respects my wish. Doctor: Tell me what I can do to make you comfortable? Patient: Honestly doctor you have done enough and I am so thankful for that. I just wish to spend my last days at home surrounded with loved ones. I have my nurse, she takes care of me. I think I am fine! Doctor: Alright my friend.

Section Header: EXAM Summary: CODE STATUS: Do not resuscitate, healthcare proxy, palliative care orders in place.

Doctor: Do you smoke? Patient: Nope. Doctor: What about alcohol? Or any kind of drugs? Patient: Nope.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: No smoking or drinking. No drugs.

Doctor: History of any illnesses, surgeries, or hospitalizations? Patient: I dislocated my wrist when I was a kid but that's all.

Section Header: PAST MEDICAL HISTORY Summary: Surgeries: None. Injuries: Dislocated wrist. Illnesses: None.

Doctor: Any pain while peeing? Patient: No. Doctor: Any change in frequency or feeling the urgency to pee? Patient: No. Doctor: And what about bladder control, any accidents? Patient: No. Doctor: Any history of syphilis or any other S T D? Patient: No, never. Doctor: Okay.

Section Header: REVIEW OF SYSTEMS Summary: GENITOURINARY: Negative frequency, negative urgency, negative dysuria, negative incontinence. No history of STDs.

Doctor: Is there any history of heart disease in your family? Patient: Yes, my dad and brother had heart vessel blockage type of disease in their forties.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Positive for coronary artery disease in her father and brother in their 40s.

Doctor: If I'm understanding correctly, you sustained an elbow injury during a fight with some other kids in Juvenile Hall? Patient: Yeah. My left elbow is killing me. Doctor: How old are you? Patient: Seventeen. Doctor: Are you having pain anywhere else? Patient: Yeah. My left ankle also hurts. Doctor: Are you able to walk without difficulty? Patient: Yeah. Doctor: Any knee pain? Patient: Not right now, but I've had left knee pain in the past. Doctor: Did you pass out or hurt your neck in any way? Patient: I didn't pass out. I hit my head against the floor when one of the kids tried to pin me down. Doctor: Do you have a headache, nausea, or blurry vision? Patient: No. Doctor: And no chest or abdominal pain? Patient: No. Doctor: Were there any weapons like knives or guns used during the fight? Patient: No.

Section Header: HISTORY of PRESENT ILLNESS Summary: This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain. He also has pain in his left ankle, but he is able to walk normally. He has had previous pain in his left knee. He denies any passing out, any neck pain at this time even though he did get hit in the head. He has no chest or abdominal pain. Apparently, no knives or guns were involved.

Doctor: Hello. Before we begin your visit, I noticed some information missing. Could I verify the information with you? Patient: Of course. Doctor: Does your family have a history of any health related problems? Patient: Oh, yeah. A lot of my family have heart problems and cancer. Doctor: I see. Do you know what kind of cancer? Patient: I'm not completely sure, but my wife may know. She's here with me right now. Doctor: Great. I'll bring her in. Guest_family. Hello. I'm his wife. Doctor: Do you know what type of cancer runs in his family? Guest_family: I do. I believe it's carcinoma. Doctor: Thank you. Sir, are there any other health related problems I should be aware of? Patient: High blood pressure and food allergies run in my family too.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension.

Doctor: Okay I am looking at you for multiple issues today. One of the biggest being swelling on your left leg. Can you tell me more about that? Patient: Yes sure. I got this swelling for almost three years now, and it has been worse for the past two to three months. Sometimes it gets better in the morning when I get up, but then throughout the day it begins to swell again. Lately it is staying bigger, and it feel uncomfortable with it being so large. The right leg also swells, but not nearly like the left leg. Doctor: How old are you, miss? Patient: I am forty four. My biggest problem is this pain in my left shoulder. I feel as if this low back pain is due to a poor mattress. Doctor: Did you hurt your shoulder? Patient: No, I don't remember hurting shoulder, but gradually I am losing some mobility. It is hard for me to get my hands behind my back or behind my head. I am losing strength in the left shoulder gradually for the last year. Doctor: Ok let's look at your labs. Patient: So far white counts are high. In April two thousand five Doctor X Y Z was asked to look at my high white count, but she thought it wasn't a problem and asked me to come for follow up. Doctor: Any other complaints? Patient: I have a lot of frequency with urination, and I get up to pee at night at least two to three times. Also, I have gained weight, I think about twelve pounds since March. Right now, I am two eighty four pounds. Doctor: Okay. So, I can see that your blood pressure is staying stable. You do take Atenolol twelve point five M G per day and Lasix as needed. Patient: Yes, that's correct. It makes me pee so much. I do not take it. Doctor: How about chest pain or shortness of breath? Patient: No chest pain, but I am gradually feeling short of breath. Doctor: What work you do? Patient: I work for the city of Wichita as bus dispatcher. My work demands sitting a lot, and just really does not move around much. But towards the end of the day my leg swells up. Doctor: Okay that's okay. Patient: I need cholesterol check right? Doctor: Yes, you do, but all the other labs are normal.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 44-year-old white female who is here today with multiple problems. The biggest concern she has today is her that left leg has been swollen. It is swollen for three years to some extent, but worse for the past two to three months. It gets better in the morning when she is up, but then through the day it begins to swell again. Lately it is staying bigger and she somewhat uncomfortable with it being so large. The right leg also swells, but not nearly like the left leg. The other problem she had was she has had pain in her shoulder and back. These occurred about a year ago, but the pain in her left shoulder is of most concern to her. She feels like the low back pain is just a result of a poor mattress. She does not remember hurting her shoulder, but she said gradually she has lost some mobility. It is hard time to get her hands behind her back or behind her head. She has lost strength in the left shoulder. As far as the blood count goes, she had an elevated white count. In April of 2005, Dr. XYZ had asked Dr. XYZ to see her because of the persistent leukocytosis; however, Dr. XYZ felt that this was not a problem for the patient and asked her to just return here for follow up. She also complains of a lot of frequency with urination and nocturia times two to three. She has gained weight; she thinks about 12 pounds since March. She now weighs 284. Fortunately, her blood pressure is staying stable. She takes atenolol 12.5 mg per day and takes Lasix on a p.r.n. basis, but does not like to take it because it causes her to urinate so much. She denies chest pain, but she does feel like she is becoming gradually more short of breath. She works for the city of Wichita as bus dispatcher, so she does sit a lot, and just really does not move around much. Towards the end of the day her leg was really swollen. I reviewed her lab work. Other than the blood count her lab work has been pretty normal, but she does need to have a cholesterol check.

Doctor: What do you do for living? Patient: I am an officer at United States Marine office, artillery repair specialist. Doctor: Do you drink alcohol? Patient: I use to drink socially but stopped two years back. Doctor: How about smoking and drugs? Patient: No not that.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He is employed as a United States Marine officer, artillery repair specialist. He was a social drinker in the past but quit altogether two years ago. He never used tobacco products or illicit/intravenous drugs.

Doctor: How are you today? Patient: I am good. Doctor: What is your past medical history? Patient: I don't have any health problems. Not yet at least. Doctor: Let's keep try to keep it that way. Patient: Yes please.

Section Header: PAST MEDICAL HISTORY Summary: Essentially noncontributory.

Doctor: Well, I am looking at your ultrasound report and honestly the only significant finding of this area is that it shows to be related to bone. Patient: Oh okay.

Section Header: LABS Summary: The only significant finding in the ultrasound of the area is that it shows this to be related to bone.

Doctor: Tell me about your family. Did anyone have any medical issues? Patient: My father is alive. He is sixty nine right now. He did have some strokes in the past. My mom on the other hand died at the age of sixty two of many kinds of heart diseases. Doctor: What about your grandparents? Patient: My maternal grandfather he also had heart issues and he died of a heart attack. Both he and my maternal grandma had some heart diseases. Their heart use to beat pretty fast.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT.

Doctor: Hi there! What brings you back to see me so soon? Patient: Hi! I have had these sores in my mouth. Doctor: How long have you had the sores? Patient: They started about ten to twelve days ago. Doctor: We have been currently treating your rheumatoid arthritis with methotrexate. How much have you been taking? Patient: Yes, we have tried lots of different treatments and methotrexate has been working well. I have been on it for ten years now. I have been taking about twenty or twenty five M G of per week. Doctor: Did we recently increase your dosage? I see in your chart that we have changed your dosage a few times. Patient: About a year ago we lowered the dosage for twenty five M G to twenty but my arthritis flared up so we went to twenty two point five. Doctor: Have you ever had any side effects from the methotrexate in the past? Patient: No. I don't think so. Doctor: Are you taking any other medications? Patient: I had a sinus infection and the doctor put me on an antibiotic. That was about two weeks ago. Doctor: Do you know what the antibiotic the doctor gave you? Patient: I don't remember the name of the antibiotic, but I know that I have taken antibiotics before and I didn't have a problem. Doctor: How long was your antibiotic course? Patient: It was three or four days long. I had to take it three times a day. Doctor: Have you ever had any allergic reactions to medications? Patient: No. Doctor: Any history of mouth sores? Patient: No. Doctor: Are you taking anything to help with the pain of the mouth sores? Patient: I took Aspirin a month ago. I started taking it again because my mouth was sore. Doctor: Have you had any other problems with your skin? Any new rashes? Patient: No. Doctor: Sorry to side track, but where is your accent from? My family is Cuban and my mom and you speak the same. Patient: What a surprise! I am Cuban. A proud fifty seven year old Cuban.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a very pleasant 57-year old white female, a native of Cuba, being seen for evaluation and treatment of sores in her mouth that she has had for the last 10-12 days. The patient has a long history of severe and debilitating rheumatoid arthritis for which she has had numerous treatments, but over the past ten years she has been treated with methotrexate quite successfully. Her dosage has varied somewhere between 20 and 25 mg per week. About the beginning of this year, her dosage was decreased from 25 mg to 20 mg, but because of the flare of the rheumatoid arthritis, it was increased to 22.5 mg per week. She has had no problems with methotrexate as far as she knows. She also took an NSAID about a month ago that was recently continued because of the ulcerations in her mouth. About two weeks ago, just about the time the stomatitis began she was placed on an antibiotic for suspected upper respiratory infection. She does not remember the name of the antibiotic. Although she claims she remembers taking this type of medication in the past without any problems. She was on that medication three pills a day for three to four days. She notes no other problems with her skin. She remembers no allergic reactions to medication. She has no previous history of fever blisters.

Doctor: Hello, miss. How are you feeling today? Patient: Terrible. My allergies are killing me right now. Doctor: Do you have a history of allergies? Patient: Yeah, I do. I had them all the time when I lived in Seattle, but they got a lot worse when I moved here. I am a strong German woman and I hate how something as little as allergies gets the best of me. Doctor: Why did you move here? Patient: I wanted to experience different cities since I'm only twenty three. Doctor: That sounds exciting. Back to your allergies now. Do you take any medication to relieve your symptoms? Patient: Here's a list of past and current medications I'm taking. Doctor: Thank you. Let me take a look. I see you took Claritin and Zyrtec in the past, correct? Did those help you? Patient: Yeah, that's correct. They were working for a bit, but then they stopped working after a while. Doctor: I see. Your notes say you took Allegra after, correct? Patient: Correct. I tried out Allegra last summer, but I don't know if it was doing its job. I tried it again two weeks ago because my allergies were getting bad, but it still didn't work. Doctor: I see. Your notes state you've tried some nasal sprays, correct? Patient: Yeah, I did. I wanted to see if they would work. Doctor: Were you prescribed these nasal sprays? Patient: Nope. I bought them at my local pharmacy. Doctor: Sounds good. I'm looking at your medical history, and it sates here you have asthma too, correct? Patient: Yeah, I've had it for a long time, but it hasn't gotten worse. Doctor: I see. Do you think you need any medication to help alleviated your asthma? Patient: No. It doesn't bother me as much as my allergies.

Section Header: HISTORY of PRESENT ILLNESS Summary: This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effectiveness. She has used Allegra also. She used that last summer and she began using it again two weeks ago. It does not appear to be working very well. She has used over-the-counter sprays but no prescription nasal sprays. She does have asthma but doest not require daily medication for this and does not think it is flaring up.

Doctor: How are you doing young man? Patient: I'm good. Thank you. Doctor: Let's see how your chest is doing. Patient: Okay. Doctor: Chest measurements look nice. No issue there. The outline also looks great. Also, there is no hunchback?

Section Header: EXAM Summary: CHEST: Normal AP diameter and normal contour without any kyphoscoliosis.

Doctor: I see here that Doctor- Patient: Yes, Doctor X referred me. My thyroid is an absolute mess. I have never been in so much pain in my seventy one years. Doctor: I'm so sorry to hear that. I hope we're able to get you the care that you need. Patient: I've been coughing up a storm. It's gotten to be way too enlarged. Doctor: It's good that you're here today to get the surgery rolling. Patient: I signed the paperwork and everything. Doctor: I'll go over the risk and benefits one more time. Any questions for me? Patient: When is the earliest I can get this done again? Doctor: Given your symptoms, I'd like to get you in in the next few days.

Section Header: HISTORY of PRESENT ILLNESS Summary: Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter. She presented now after informed consent for the procedure, understanding the inherent risks and complications and risk-benefit ratio.

Doctor: Are you allergic to any medications? Patient: No, I am not allergic to any drugs. Doctor: Okay. Are you sure? Patient: Yes.

Section Header: ALLERGY Summary: No drug allergies.

Doctor: I see here that you're allergic to grapefruit and peanuts. Do you happen to be allergic to any medications you've taken in the past? Patient: Nah, just allergic to grapefruit and peanuts. Doctor: Gotcha. Do you carry an Epi pen around with you? Patient: I try to bring it with me everywhere I go.

Section Header: ALLERGY Summary: There are no known allergies.

Doctor: So, tell me about your family, any illness or anything that runs in the family. Patient: Um, not that I know of. Doctor: Okay.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Unremarkable.

Doctor: Any medical issues in the past? Patient: No, I have a very clean history. Doctor: That's good for you. Any kind of surgery or hospitalization? Patient: No.

Section Header: PAST MEDICAL HISTORY Summary: Noncontributory.

Doctor: Let's talk a little bit about your family, okay? Doctor: Does anyone in your family had any medical issues? Patient: Yeah, my parents died of cancer. Doctor: Which cancer? How old were they? Patient: I don't know which cancer they had, but my mother was forty two and dad was sixty two. Doctor: Who else is there in the family? Patient: Oh, I have a big family. I have four sisters, one brother and two half brothers. One of my half brother's has asthma.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Mother died age 42 of unknown type cancer. Father died age 62 of unknown type cancer. 4 sisters, one brother and 2 half-brothers. One of the half-brothers has asthma.

Doctor: So, tell me something, does asthma run in your family? Patient: No, I think I am the only one who has it. Even my parents were surprised when I developed it, as no one else has it. Doctor: Yeah, it happens.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: No significant family history.

Doctor: Welcome in, sir. I am Doctor Gray. Patient: Thank you. It's nice to meet you. Doctor: What is your past medical history? Patient: I had surgery on my shoulder thirteen years ago and after the surgery I lost my sense of smell. I still can't smell. I also can't see very well in my right eye. Doctor: How old are you? Patient: I am seventy six. Doctor: Do you get headaches? Patient: No. Doctor: Do you have any nasal drainage? Patient: No. Doctor: Do you ever experience any weakness or numbness throughout or localized to an area of the body. Patient: No. Doctor: Have you had any resent weight loss? Patient: No.

Section Header: HISTORY of PRESENT ILLNESS Summary: 76 y/o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation. He continues to be anosmic, but has also recently noted decreased vision OD. He denies any headaches, weakness, numbness, weight loss, or nasal discharge.

Doctor: Do thyroid problems run in your family? Patient: No.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.

Doctor: Are you taking any medicines? Patient: Just Tylenol for my pain. Doctor: Okay.

Section Header: MEDICATIONS Summary: Tylenol for pain.

Doctor: Good afternoon, sir. Did you see the nurse already? Patient: Yes, I just saw her. Doctor: Great, you're seventy eight years old, correct? Patient: Yes, I'm not as young as I used to be. Doctor: Who is? What seems to be the problem today, sir? Patient: I have right hand pain, and it's been there for a while now. Doctor: Are you having numbness sir? Patient: Yes, and I can't move it very well, either. Doctor: Which fingers are you having these symptoms in? Patient: Well, I told you it's all in the right hand, but it's in the index and middle fingers. Doctor: Are your fingers catching? Patient: What does that mean, doctor? Doctor: Are you having any problems extending your fingers? Patient: Yes, they seem to lock up when I try to extend my fingers. Doctor: Have you seen another doctor for this? Patient: Yes, I had an E M G and it showed, um, carpal tunnel on both hands. Doctor: It's in both hands, but the right is worse than the left, correct? Patient: Yes, that's correct. Doctor: What treatments have you had for this? Patient: I only had an injection so far. Doctor: Did this help at all? Patient: Well, some, but it was really only temporary relief. Is there surgery for this? Doctor: Yes, I think you'd be a good candidate for surgery. Patient: What are the risks of infection from the surgery? Doctor: It's less than one percent. We use prophylactic antibiotics to control for infection the entire time. Patient: Even though it's on my hand, will I be asleep for this procedure? Doctor: Yes, you won't feel a thing. Patient: Okay, yes. I'd like to do the surgery.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 78-year-old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking. The patient was diagnosed with carpal tunnel syndrome on bilateral hands the right being worse than the left. He had positive EMG findings as well as clinical findings. The patient did undergo an injection, which only provided him with temporary relief and is for this reason, he has consented to undergo the above-named procedure. All risks as well as complications were discussed with the patient and consent was obtained.

Doctor: Hi are you married? Patient: Yes, I am. Doctor: Do you have kids? Patient: Yes, I had a son, but unfortunately, he died in a car accident. It was five years ago. Doctor: Where do you work? Patient: I work in a pharmaceutical company as a salesperson. Doctor: Do you smoke or drink or at any time tried any illicit drug? Patient: No, I've never smoked. I have tried a beer once, but I never liked it. Doctor: What about drugs? Patient: No, never did that.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Married. One son deceased. Salesperson. Denied tobacco/ETOH/illicit drug use.

Doctor: Are you going to visit rehab? Patient: Yes, what choice do I have? Doctor: Yes, please do visit Mercy Manor for P T and Rehab. Patient: Yes, I will. Doctor: That will help your right side hip pain. Patient: I think so too.

Section Header: ASSESSMENT Summary: Right hip pain, the patient to undergo physical therapy and rehabilitation at Mercy Manor.

Doctor: Can you tell me about your Immunizations? Patient: Yeah, I had them all. Doctor: Good, looks like you are up to date.

Section Header: IMMUNIZATIONS Summary: Up-to-date.

Doctor: Welcome back to the clinic. How are you feeling today? Patient: Thank you. I am doing better. Doctor: It looks like we are following up on your severe osteoarthritis in both knees. And you also have been experiencing some flexion contracture limitations. Patient: Um hum. Doctor: How is your physical therapy going? Patient: It is going really well. She kicks my butt but it seems to be helping. Doing my exercises at home is really helping. Doctor: Were you not doing them in the beginning? Patient: No, I wasn't. She got on me to start doing them and I have definitely seen the difference. Doctor: Have you experienced any worsening of pain since you were last seen? Patient: Well, the right knee is worse than the left? It mostly hurts after physical therapy. Doctor: Can you describe what the pain feels like? Patient: It feels achy. Doctor: Is it a continuous pain, or? Patient: No. It is not all the time. Every once and a while. It feels stiff all the time. Doctor: Any weakness or instability? Patient: No. Doctor: Any burning sensations associated with the pain? Patient: No. Doctor: How long have you been dealing with this? Patient: Several months. Doctor: Have you had any trouble sleeping? Patient: No. When I sit down or lie down at night there's no pain. Doctor: So, the pain is when you are weight bearing, right? Patient: Yeah. And it hurts when I move around. It makes it difficult to do things. Doctor: Have you noticed any pain with the cold weather change? Patient: No, I have not noticed anything. Doctor: I am just going to take a look here. Patient: Okay. Doctor: I don't see any swelling or redness. And I don't feel any warmth coming from the area. Have you noticed any of these symptoms? Patient: Nope. Doctor: Any radiating pain through the knees here? Patient: No. Doctor: Any pain any where else in the body? Patient: No, just the knees. Doctor: So, no pain in the hips or back? Patient: Nope.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left. Pain: Localized to the bilateral knees right worse than left. Quality: There is no swelling, no redness, or warmth. The pain is described as aching occasionally. There is no burning. Duration: Months. Associated symptoms: Includes stiffness and weakness. There is no sleep loss and no instability. Hip Pain: None. Back pain: None. Radicular type pain: None. Modifying factors: Includes weight bearing pain and pain with ambulation. There is no sitting, and no night pain. There is no pain with weather change.

Doctor: Hi, what is going on? Guest_family: She was doing well until this morning, but now she can barely move her right arm and is having speech issues. She can't seem to comprehend words. I think it is a stroke. Doctor: We see this a lot at A B C Medical Center. I am glad you came. You just saw Doctor H, right? Guest_family: Yes. We did a C T head scan and labs. Doctor: Okay. Where is she living? With you? Guest_family: No. She is at the Life Care Center. Doctor: Ma'am, do you have headache or chest pain? Patient: What? What? Huh? Guest_family: She has not complained of anything like that. Doctor: Ma'am. Do you have vision issues? Patient: What? I can see. Of course I can see. Doctor: Any shortness of breath? Guest_family: She is breathing fine. Doctor: Have your symptoms improved at all? Or have they worsened since this morning? Guest_family: No. They have stayed constant.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. She was subsequently sent to ABC Medical Center for evaluation and treatment. At ABC, the patient was seen by Dr. H including labs and a head CT which is currently pending. The patient has continued to have right-sided arm and hand weakness, and has difficulty expressing herself. She does seem to comprehend words. The daughter states the patient is in the Life Care Center, and she believes this started this morning. The patient denies headache, visual changes, chest pain and shortness of breath. These changes have been constant since onset this morning, have not improved or worsened, and the patient notes no modifying factors.

Doctor: I think you have a muscular strain. Patient: Yeah. Doctor: So right side shoulder strain and maybe a little bit of nerve compression. Patient: Oh really! Doctor: Maybe. I will do further evaluation and treatment. Patient: Okay.

Section Header: ASSESSMENT Summary: Right shoulder pain, most likely secondary to muscular strain. He does have a very mild evidence of impingement.

Doctor: Can you tell me more about your daughter, ma'am? Guest_family: Sure, well she's fourteen now, um, she's right handed, and she just started high school. Doctor: Has she ever had surgery? Guest_family: Yeah, she had an, um, lipomyomeningocele repair when she was about three days old, and then again when she was three and a half years old. Doctor: When was her last surgery? Guest_family: Um, it was in March of nineteen ninety five. Doctor: How did she do following the second surgery? Guest_family: She did well, honestly. Doctor: So, what brings you in for a visit today? Patient: Well, I've been having some leg pain on the side of my legs. Doctor: How long have you had this pain? Patient: It's been several months at this point. Doctor: When is your pain the worst? Patient: Um, it's the worst at night, I have to take medicine for the pain. Doctor: What do you take? Guest_family: She takes Advil, Motrin, and Tylenol P M. Doctor: Wow, that's a lot. Looks like you have some patch sensory loss in the L four to S one region. Are you going to the bathroom regularly? Patient: Yeah, there's no problems there. I do have some loss of feeling in my big toe and calf though.

Section Header: HISTORY of PRESENT ILLNESS Summary: Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. The last surgery was in 03/95. She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM. Denies any new bowel or bladder dysfunction or increased sensory loss. She had some patchy sensory loss from L4 to S1.

Guest_clinician: How is the patient's condition now? Doctor: Well, he has improved clinically but would require acute care. Guest_clinician: Oh, I see.

Section Header: DISPOSITION Summary: Clinically improved, however, requiring acute care.

Doctor: Good morning, ma'am. Can you confirm your age for me, please? Patient: Good morning, I'm sixty five years old, doctor. Doctor: How are you recovering from your operation? Patient: I'm doing okay. Can you remind me what operation I had? Doctor: Um, we did a left upper lobectomy for your stage I A non small cell lung cancer. Patient: Thank you, doctor. Doctor: Absolutely, do you have the results of your pelvic C T? Patient: Yes, I have the report right here. Doctor: Thank you, so this shows an enlarging simple cyst of the left kidney. Patient: What can we do about this? Doctor: Well, that's why we did the barium swallow, which showed a small hiatal hernia with minimal reflux. Patient: Oh, yeah, I remember that. Doctor: So, I have your x rays from November twenty third two thousand nine here, we did an A P and lateral view, and they're normal. Patient: Oh, well that's good too. Doctor: Are you having any pain with swallowing food? Patient: Yes, I get some chest pain, but I'd say it's pretty mild. Look at my calf, doctor, it's much bigger than the right one. Doctor: Chest pain is probably due to tertiary contractions with some delayed emptying. Is it tender? Patient: No, there's no real tenderness. Doctor: How long has this calf been enlarged? Patient: Um, it's been several months at this point. Doctor: Have you ever had D V T? Patient: Yes, um, in nineteen seventy five, and in nineteen eighty five. Doctor: Are you having any abnormal weight loss? Patient: No, everything is normal there, and I'm eating normally. Doctor: What about any cold or flu symptoms? Any fever or chills? Patient: No, that's all fine too. Doctor: Any new aches or pains? Patient: No, all my muscles feel pretty good. Doctor: Have you had a cough, or coughed up any blood. Patient: That's a negative, doctor. Doctor: What about shortness of breath while at rest or difficulty breathing with exercise? Patient: No, that's normal too. I'm breathing just fine.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit. She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney. She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux. She has a minimal delayed emptying secondary tertiary contractions. PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates. Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia. This most likely is secondary to tertiary contractions with some delayed emptying. She has also had increased size of the left calf without tenderness, which has not resolved over the past several months. She has had a previous DVT in 1975 and 1985. She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.

Doctor: Let's talk about your family's medical history. Patient: Hm, well both my father and my brother had colon cancer. My daughter was detected with breast cancer. Doctor: Do you remember what her age was? Patient: Yeah, she was forty. Doctor: I see. Anything else? Patient: Well, I have a heart condition and high blood pressure. I also had a stroke. Doctor: Okay.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Positive for heart disease, hypertension and cerebrovascular accidents. Family history is positive for colon cancer affecting her father and a brother. The patient has a daughter who was diagnosed with breast cancer at age 40.

Doctor: Any fever? Patient: No. Doctor: No nausea and vomiting or black stool? Did you notice any blood in your stools? Patient: Nope, nothing like that. Doctor: Did you notice any blood in urine or painful urination? Patient: No. Doctor: Okay, any chest pain? Patient: Um, no. Doctor: Any shortness of breath, cough or cold like symptoms? Patient: Nope. Doctor: No diabetes or thyroid problem, right? Patient: Absolutely not! Doctor: Looks like you have no history of C V A or stroke. Patient: Correct. Doctor: Everything else looks fine. Patient: Cool. Doctor: Your eyes, nose, and throat look good.

Section Header: REVIEW OF SYSTEMS Summary: CONSTITUTIONAL: No fever. ENT: Not remarkable. RESPIRATORY: No cough or shortness of breath. CARDIOVASCULAR: The patient denies chest pain. GASTROINTESTINAL: No nausea. No vomiting. No history of GI bleed. GENITOURINARY: No dysuria. No hematuria. ENDOCRINE: Negative for diabetes or thyroid problems. NEUROLOGIC: No history of CVA or TIA. Rest of review of systems is not remarkable.

Doctor: How are you doing miss? How are your sugar numbers coming along? Patient: I'm doing good. Thank you. Sugar has consistently been one hundred and thirty five or under it. Doctor: How are you checking it? Patient: I have a glucose monitor at home I'm using that only. Doctor: Nice. Did you eat anything in the morning today? Patient: No, I'm fasting for my test. Doctor: Okay, let's see. We have an Accu Chek here in our office. I will do a quick sugar test for you, and this will be a fasting sugar test. It will be just a quick prick on your finger. Patient: Don't worry doctor. I'm used to poking my finger all the time. Doctor: Let's see what we got here. Your reading says one hundred and twenty. I will write it down for my record. Are you being active? Patient: Yes, I'm exercising as a rule three times every week. I don't miss it. Doctor: Do you feel any tingling or numbness or any kind of cramps? Patient: Nope. Doctor: Any kind of blurry vision? Patient: Nope. Doctor: Any weight loss? Patient: Not that I notice.

Section Header: HISTORY of PRESENT ILLNESS Summary: Overall, she has been doing well. Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek. She is exercising three times per week. Review of systems is otherwise unremarkable.

Doctor: How did your last visit go with the cardiologist? Patient: Good. Doctor: It looks like they diagnosed you with sick sinus syndrome. Do you have any questions about this new diagnosis? Patient: No, she explained everything to me. I'm planning to follow-up with her in the next two weeks. Doctor: Great. So it looks like your past medical history is the same? Nothing new other than the sick sinus syndrome.

Section Header: DIAGNOSIS Summary: Sick sinus syndrome. The rest of her past medical history remained the same.

Doctor: So Mister J, where do you stay? Patient: Oh, I stay at a care facilit. It's very near to your clinic. Have you heard about this place called South Valley Care Center? Doctor: Oh yes, I have heard of it.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient has been residing at South Valley Care Center.

Doctor: How are you Mister James? Patient: I have been better! Doctor: Oh, tell me what's going on with you? Patient: I have this leg pain on my left side. Doctor: Hm, left leg pain? Patient: Yeah.

Section Header: CHIEF COMPLAINT Summary: Left leg pain.

Doctor: Have you ever had an allergic reaction to drugs you've taken in the past? Patient: More than once. I've reacted poorly to sulfa drugs, penicillin, and some mycins. I also think I'm allergic to contrast medium.

Section Header: ALLERGY Summary: She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins.

Doctor: Hey, do you smoke cigarettes? Patient: Yes I do smoke. Do you? Doctor: Nope. Are you planning on quitting? Patient: No, I just smoke one pack per day, it's not bad. Doctor: Oh my God. No. It is bad. You should think about quitting. Patient: Okay I will think about it. Doctor: Where do you work? Patient: I work at local christmas tree farm.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient works at a local Christmas tree farm. He smokes cigarettes approximately one pack per day.

Doctor: Are you still working? Patient: Retired some time ago. Doctor: What was your profession? Patient: I used to work at a car repair shop called Champion Automotive Company. Doctor: Nice. How did you enjoy the work? Patient: I liked it a lot, but there came a time where I knew it was the end of the road for me. I'm really enjoying retirement. Doctor: I bet. I have cousin who owns a car repair shop. He's almost always busy. Patient: Yeah, it can be a lot sometimes. Doctor: Any smoking, drinking, or hard drugs? Patient: I can confidently say no to each one. Doctor: Great to hear.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Retired employee of Champion Automotive Co. Denies use of TOB/ETOH/Illicit drugs.

Guest_clinician: Do you have his full medical history? Doctor: Yes, I confirmed with his wife. He had a CABG done in ninety one. He has a history of radical prostate cancer for which he underwent a radical prostatectomy and nephrectomy. Guest_clinician: Any additional surgeries? Doctor: Yes. He had lumbar surgery twice before. He suffered from lumbar stenosis many years ago in the sixties and seventies. He's actually due for another lumbar surgery with Doctor Y. He takes Percocet daily for his back pain. He also has a history of hypertension and hyperlipidemia. Guest_clinician: I think I got it all down.

Section Header: PAST MEDICAL HISTORY Summary: Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia. Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.

Doctor: Do you have any history of major surgeries? Patient: No. Nothing major.

Section Header: PAST SURGICAL HISTORY Summary: Nothing significant.

Doctor: Good morning, sir. Patient: Good morning, doctor. Doctor: Before we begin, have you ever had surgery? Patient: Yes, I had a vasectomy some time ago.

Section Header: PAST SURGICAL HISTORY Summary: Vasectomy.

Doctor: Okay, so let's go over your medications. I'd like you to take these to help your muscle spasms. Patient: Sounds good. Doctor: I've prescribed eight hundred milligrams of Ibuprofen to be taken every eight hours as needed along with Tylenol number three every six hours as needed. Patient: What does the number three stand for? Doctor: Tylenol number three is combined with Codeine. Patient: Okay, I see. Doctor: And finally, I'm prescribing Methocarbamol seven fifty milligrams which needs to be taken four times a day for maximum relief. Do you have any questions for me? Patient: No, I think you answered them all.

Section Header: MEDICATIONS Summary: Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid.

Doctor: How are you doing today, sir? Patient: Honestly, I'm pretty sick today. I've got a lot going on. Doctor: How long have you been feeling this way? Patient: Well, it's been off and on for about a month now. Doctor: Has it been getting worse recently? Patient: Yeah, it has over the last couple weeks. Doctor: What are your symptoms? Patient: Well, I'm coughing up this yellow phlegm. It feels like everything is in my chest. Doctor: What medications have you been taking for this? Patient: I've been taking Allegra D sometimes, but I'm almost out. I need a refill. Doctor: What other problems are you having? Patient: My foot keeps breaking out. Doctor: Has this improved at all? Patient: Well, it was for a while, but now it's really bad again. Doctor: Have you been diagnosed with any conditions before? Patient: I had, um, tinea pedis before. Doctor: How was this treated? Patient: They gave me Nizoral cream. Doctor: It has been getting warmer recently, I don't think that this isn't necessarily a coincidence that you're having these symptoms now. Patient: Yeah, I work in the flint and it's really hot and humid down there. Doctor: What else are you dealing with, sir? Patient: I have this wart on my right middle finger, are you able to freeze it off? Doctor: Have you ever done that before? Patient: Yeah, you have done it before, and it went away. Doctor: If we've done it before, we can do it again. Patient: Cool, can we do blood work, too? I want to check on my prostate. Doctor: Well, that's called P S A. Patient: Can I have that done? I'm concerned. I am fifty after all. Doctor: Sure, we can check your cholesterol too. I know you have history of it being high. Patient: You know, I've been working on that. I quit smoking for a while, but I got back into it. Doctor: That's good, it's really hard to quit. Patient: Yeah, I tried chewing tobacco, but it's not the same. Doctor: Be sure to keep trying to quit smoking.

Section Header: HISTORY of PRESENT ILLNESS Summary: This patient presents to the office today for a checkup. He has several things to go over and discuss. First he is sick. He has been sick for a month intermittently, but over the last couple of weeks it is worse. He is having a lot of yellow phlegm when he coughs. It feels likes it is in his chest. He has been taking Allegra-D intermittently, but he is almost out and he needs a refill. The second problem, his foot continues to breakout. It seems like it was getting a lot better and now it is bad again. He was diagnosed with tinea pedis previously, but he is about out of the Nizoral cream. I see that he is starting to breakout again now that the weather is warmer and I think that is probably not a coincidence. He works in the flint and it is really hot where he works and it has been quite humid lately. The third problem is that he has a wart or a spot that he thinks is a wart on the right middle finger. He is interested in getting that frozen today. Apparently, he tells me I froze a previous wart on him in the past and it went away. Next, he is interested in getting some blood test done. He specifically mentions the blood test for his prostate, which I informed him is called the PSA. He is 50 years old now. He will also be getting his cholesterol checked again because he has a history of high cholesterol. He made a big difference in his cholesterol by quitting smoking, but unfortunately after taking his social history today he tells me that he is back to smoking. He says it is difficult to quit. He tells me he did quit chewing tobacco. I told him to keep trying to quit smoking.

Doctor: Hi, how's it going? Patient: Not too bad, can't complain. Doctor: It looks like the weather's been warming up, which is nice. Patient: Yeah, I can't wait to spend some time with my kids this afternoon. Doctor: Aw, how many kids do you have? Patient: Two. Doctor: And are you single, dating, married? Patient: I've been married to my wife for about ten years now. Doctor: Congratulations! That's a decade, my friend. Patient: Hah, it sure is. Doctor: Are you from the area? Patient: I was actually born in Oklahoma. Doctor: How long- Patient: Moved up here in O seven. Doctor: Awesome. I moved here in O nine, so two years after you. Patient: No way! How funny. Where from? Doctor: I'm originally from Kentucky. And I have to do the routine ask, but any drinking, smoking, or illicit drug use? Patient: No to all of the above. Doctor: Got it.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: No tobacco, alcohol or illicit drug use. Patient is born and raised in Oklahoma . No known exposures. Married with 2 children.